Ivf and Sample Contract - Excel by aus12721

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									                                                                     OXFORD HEALTH PLANS (CT), INC.
                                                                       OXFORD HMO PLAN SELECT
                                                                        SUMMARY OF COVERAGE
                                                                          Metro North Railroad
                                                                            Freedom Network

BENEFIT                                                               COVERAGE

FINANCIAL
Deductible:                                         Single            None
                                                    Family            None
Coinsurance                                                           None
Maximum Out-of-Pocket:                              Single            Not Applicable
                      (Including Deductible)        Family            Not Applicable
Maximum Lifetime Benefit Per Member                                   Unlimited
Financial Accumulation Period:                                        Not Applicable

PREVENTIVE CARE
Adult Preventive Care                                                 No Charge
Infant and Pediatric Preventive Care                                  No Charge
Preventive Dental for Children (Through age 11)                       No Charge

OUTPATIENT CARE
Primary Care Physician Office Visits                                  $15 copay per visit
Specialist Office Visits                                              $15 copay per visit
Outpatient Facility Surgery**                                         No Charge
Laboratory Services                                                   At Participating Laboratories: No Charge
MRIs, MRAs, CT Scans, PET Scans and Ultrasound**                      No Charge
Radiology Services**                                                  No Charge

HOSPITAL CARE
Physician's and Surgeon's Services **                                 No Charge
Semi-Private Room and Board **                                        No Charge
All Drugs and Medication                                              No Charge

EMERGENCY CARE
Ambulance Service When Medically Necessary                            No Charge
At Hospital Emergency Room                                            $50 copay; waived if admitted
(If member is admitted to the hospital, notification is required.)
Emergency Care in Urgi-Center                                         $15 copay per visit

MATERNITY CARE
Prenatal and Post-Natal Care **                                       $15 copay per initial visit
Hospital Services for Mother and Child **                             No Charge

SKILLED NURSING FACILITY
30 Days per Calendar Year **                                          No Charge

HOSPICE CARE (210 Days Combined Inpatient, Outpatient and Home Hospice)
Inpatient Care**                                          No Charge
Outpatient Care**                                         No Charge
Home Hospice**                                            No Charge

HOME HEALTH CARE
Home Care Visits - 80 Visits Per Calendar Year**                      No Charge
Physician House Calls                                                 $15 copay per visit

SUBSTANCE USE DISORDER SERVICES
Inpatient Rehabilitation**                                            No Charge
Outpatient Rehabilitation**                                           $15 copay per visit

MENTAL HEALTH CARE
Inpatient Care**                                                      No Charge
Outpatient Facility**                                                 $15 copay per visit
Office Visits**                                                       $15 copay per visit




CTLG HMO_07.01.10_v.2                                                                                            January 1, 2011   Page 1 of 2
BENEFIT                                                                 COVERAGE

ALLERGY CARE
Testing and Treatment                                                   $15 copay per visit

ALTERNATIVE MEDICINE
Chiropractic Care                                                       $15 copay per visit
Naturopathic Care                                                       $15 copay per visit
Acupuncturist Care - $500 limit                                         $15 copay per visit

SHORT TERM REHABILITATION
60 Consec. Inpatient Days per Condition/Lifetime**                      No Charge
60 Outpatient Visits per Condition/Lifetime                             $15 copay per visit
Precertification upon initial Visit**

DURABLE MEDICAL EQUIPMENT
Durable Medical Equipment                                               No Charge
$1,500 Maximum per Calendar Year
Precertification required for items over $500**

MEDICAL SUPPLIES
Medical Supplies When Medically Necessary                               $15 copay per item

INFERTILITY TREATMENT
Basic, Comprehensive and Advanced Infertility Services. (Covers all services in compliance with the CT Infertility Mandate)
Limits- Two cycle limit per lifetime for IVF, GIFT, ZIFT & low tubal ovum transfer.
Three cycle limit per Lifetime for Intrauterine Insemination
Four cycle limit per Lifetime for Ovulation Induction
If Administered by ObGyn**                                            $15 copay per visit
Specialist Office Visit**                                             $15 copay per visit
Outpatient Facility Service**                                         No Charge
Inpatient Facility Service**                                          No Charge

INFERTILITY MEDICATIONS-No Limit
Infertility Medications                                                 $15 copay per item

HEARING AIDS
This benefit is limited to $1,500 per member per                        No Charge
12 month period.


PRESCRIPTION DRUGS (Includes Oral Contraceptives)
Tier 1***                                                               $10 copay
Tier 2***                                                               $20 copay
Tier 3***                                                               $35 copay




DEPENDENT ELIGIBILITY:
Eligible dependents include the employee's spouse and dependent children until the child reaches age 26 in the following situations:
The Dependent Child is not married and resides in the State of Connecticut, or is a full time student in a college outside of the State of Connecticut.




**These services require precertification through Oxford. Members must call Oxford at 1-800-444-6222 at least 14 days in advance of
request of treatment to request precertification. Out-of-network Urgent Care, when properly precertified may be paid at member's copay.
**Mental health and substance use disorder services can be precertified through Oxford's Behavioral Health Department by calling 1-800-201-6991.
***Prescription medications ordered through the Mail Order Drug Program are subject to 2 applicable retail pharmacy copays.
***The Prescription Drug Benefit is based on a Per Contract Year limit for any applicable deductibles and/or maximum limits.



Please Note:This sample summary of coverage is provided for informational purposes only. The applicable Summary of Benefits will be issued
to eligible enrolled members as part of the Certificate of Coverage. Coverage is subject to the terms and conditions of the Certificate.
Refer to the Certificate of Coverage for a more complete listing of all benefits, limitations, and exclusions which include, among other services not authorized by Oxford,
cosmetic surgery, routine foot care, custodial care, personal comfort or convenience items, private or special duty nursing, learning and behavioral disorders,
Worker's Compensation, military service-related conditions, or, unless otherwise stated, dental services and vision correction services and supplies.

Benefits are subject to final approval by the Department of Insurance and therefore may be subject to change.




CTLG HMO_07.01.10_v.2                                                                                                                     January 1, 2011                     Page 2 of 2
Group Name:                                              Metro North Railroad

Group #

CSP Description:

Eff. Date:                      1/1/2011



                                                                                Group Financial Information


                                                                                       In-Network


             Plan Design:             Copay Plan



             Office Copay:            $15


                         Primary                   $15

                         Specialist                $15




             ER Copay:                ST:$50




             Single Deductible:       N/A


             Deductible Multiplier:    N/A


             Family Deductible:                    N/A

             Coinsurance:             N/A


             Coinsurance Max:         None


                                      Single MOOP:                     N/A
                                      Family MOOP:                     N/A


             Financial Accumulator:     N/A
                                          Prescription Plan

Prescription Drugs:   Yes                           Deductible:

RX Copays:            $10/20/35                     Contraceptives:

Tier 1                       $10 copay

Tier 2                       $20 copay              Mail Order Copay:

Tier 3                       $35 copay




                                         Benefits and Riders



DME:                   ST: $1500 limit              Outpatient Physical Therap

Skilled Nursing:       ST: 30 days                  Vision Rider:

Acupuncture:           RD: $500                     Dental Rider:




                                         Dependent Eligibility

Domestic Partners:     ST: Not Covered
                             Product:          HMO Select


                             Network:                 Freedom Network




ial Information


work




           Hospital Copay:     ST: No Charge

                                                  No Charge
ption Plan

  Deductible:          None


  Contraceptives:      Yes




  Mail Order Copay:    2x Rx Copay




and Riders



  Outpatient Physical Therapy:       ST: 60 visits


  Vision Rider:                      ST: None


  Dental Rider:                      ST: None




nt Eligibility

								
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